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Kubota-Mishra E, Huang X, Minard CG, Astudillo M, Refaey A, Montes G, Sisley S, Ram N, Winter WE, Naylor RN, Balasubramanyam A, Redondo MJ, Tosur M. High Prevalence of A-β+ Ketosis-Prone Diabetes in Children with Type 2 Diabetes and Diabetic Ketoacidosis at Diagnosis: Evidence from the Rare and Atypical Diabetes Network (RADIANT). Pediatr Diabetes 2024; 2024:5907924. [PMID: 38765897 PMCID: PMC11100136 DOI: 10.1155/2024/5907924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background A-β+ ketosis-prone diabetes (KPD) in adults is characterized by presentation with diabetic ketoacidosis (DKA), negative islet autoantibodies, and preserved β-cell function in persons with a phenotype of obesity-associated type 2 diabetes (T2D). The prevalence of KPD has not been evaluated in children. We investigated children with DKA at "T2D" onset and determined the prevalence and characteristics of pediatric A-β+ KPD within this cohort. Methods We reviewed the records of 716 children with T2D at a large academic hospital and compared clinical characteristics of those with and without DKA at onset. In the latter group, we identified patients with A-β+ KPD using criteria of the Rare and Atypical Diabetes Network (RADIANT) and defined its prevalence and characteristics. Results Mean age at diagnosis was 13.7 ± 2.4 years: 63% female; 59% Hispanic, 29% African American, 9% non-Hispanic White, and 3% other. Fifty-six (7.8%) presented with DKA at diagnosis and lacked islet autoantibodies. Children presenting with DKA were older and had lower C-peptide and higher glucose concentrations than those without DKA. Twenty-five children with DKA (45%) met RADIANT A-β+ KPD criteria. They were predominantly male (64%), African American or Hispanic (96%), with substantial C-peptide (1.3 ± 0.7 ng/mL) at presentation with DKA and excellent long-term glycemic control (HbA1c 6.6% ± 1.9% at follow-up (median 1.3 years postdiagnosis)). Conclusions In children with a clinical phenotype of T2D and DKA at diagnosis, approximately half meet criteria for A-β+ KPD. They manifest the key characteristics of obesity, preserved β-cell function, male predominance, and potential to discontinue insulin therapy, similar to adults with A-β+ KPD.
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Affiliation(s)
- Elizabeth Kubota-Mishra
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Xiaofan Huang
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Marcela Astudillo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | | | - Graciela Montes
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Sisley
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - Nalini Ram
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - William E. Winter
- Department of Pathology, University of Florida, Gainesville, FL, USA
| | - Rochelle N. Naylor
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Departments of Pediatric and Medicine, University of Chicago, Chicago, IL, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Maria J. Redondo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Mustafa Tosur
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - RADIANT Study Group
- The RADIANT Data Coordinating Center, Health Informatics Institute, University of South Florida, Tampa, FL, USA
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Hao S, Cossen K, Westbrook AL, Umpierrez GE, Vellanki P. Diabetic Ketoacidosis and Long-term Insulin Requirements in Youths with Newly Diagnosed Type 2 Diabetes During the SARS-CoV-2 Pandemic. Endocr Pract 2023; 29:754-761. [PMID: 37451650 PMCID: PMC10910395 DOI: 10.1016/j.eprac.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE SARS-CoV-2 infection increases the risk of diabetes and diabetic ketoacidosis (DKA) in both adults and children. We investigated the clinical course of new-onset type 2 diabetes in youth presenting with DKA during the COVID-19 pandemic. METHODS This single-center retrospective cohort study included 148 subjects with obesity aged 10 to 21 years, admitted with DKA from January 2018 to January 2022. Groups were defined by the presence of DKA precipitant: any infection (n = 38, 26%), which included the SARS-CoV-2 (n = 10, 7%) and other infection (n = 28, 19%) groups, and no infection (n = 110, 74%). The primary outcome was insulin discontinuation within a 12-month follow-up. RESULTS The mean age was 14.9 years (IQR, 13.8-16.5), and age-adjusted body mass index (%) was 99.1 (IQR, 98.0-99.5) with 85.8% identifying as Black or Hispanic. There were no differences in DKA severity among groups. The incidence of DKA was higher during the pandemic (March 2020-January 2022, n = 117) than in the prepandemic period (January 2018-February 2020, n = 31). Within the first year after the acute DKA episode, 46 patients discontinued all insulin within 9 months (IQR, 4-14). Sixteen subjects restarted insulin 10 months (IQR, 6.5-11.0) after insulin discontinuation. Infection with SARS-CoV-2 at diagnosis was not associated with the likelihood (P =.57) or timing (P =.27) of discontinuing all insulin within 1 year, nor was having any infection. CONCLUSION The incidence of DKA at the onset of type 2 diabetes was higher during the SARS-CoV-2 pandemic than in the prepandemic period. SARS-CoV-2 infection was not associated with DKA severity or insulin discontinuation within the first year of diagnosis in youth with new-onset type 2 diabetes and DKA.
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Affiliation(s)
- Shuai Hao
- Department of Pediatrics, Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta, Georgia
| | - Kristina Cossen
- Department of Pediatrics, Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia
| | - Priyathama Vellanki
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia.
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Zheng J, Shen S, Xu H, Zhao Y, Hu Y, Xing Y, Song Y, Wu X. Development and validation of a multivariable risk prediction model for identifying ketosis-prone type 2 diabetes. J Diabetes 2023; 15:753-764. [PMID: 37165751 PMCID: PMC10509513 DOI: 10.1111/1753-0407.13407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/14/2023] [Accepted: 04/25/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND To develop and validate a multivariable risk prediction model for ketosis-prone type 2 diabetes mellitus (T2DM) based on clinical characteristics. METHODS A total of 964 participants newly diagnosed with T2DM were enrolled in the modeling and validation cohort. Baseline clinical data were collected and analyzed. Multivariable logistic regression analysis was performed to select independent risk factors, develop the prediction model, and construct the nomogram. The model's reliability and validity were checked using the receiver operating characteristic curve and the calibration curve. RESULTS A high morbidity of ketosis-prone T2DM was observed (20.2%), who presented as lower age and fasting C-peptide, and higher free fatty acids, glycated hemoglobin A1c and urinary protein. Based on these five independent influence factors, we developed a risk prediction model for ketosis-prone T2DM and constructed the nomogram. Areas under the curve of the modeling and validation cohorts were 0.806 (95% confidence interval [CI]: 0.760-0.851) and 0.856 (95% CI: 0.803-0.908). The calibration curves that were both internally and externally checked indicated that the projected results were reasonably close to the actual values. CONCLUSIONS Our study provided an effective clinical risk prediction model for ketosis-prone T2DM, which could help for precise classification and management.
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Affiliation(s)
- Jia Zheng
- Geriatric Medicine Center, Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Department of EndocrinologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouPeople's Republic of China
| | - Shiyi Shen
- Geriatric Medicine Center, Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Department of EndocrinologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouPeople's Republic of China
| | - Hanwen Xu
- Geriatric Medicine Center, Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Department of EndocrinologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouPeople's Republic of China
| | - Yu Zhao
- Geriatric Medicine Center, Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Department of EndocrinologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouPeople's Republic of China
| | - Ye Hu
- Geriatric Medicine Center, Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Department of EndocrinologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouPeople's Republic of China
| | - Yubo Xing
- Geriatric Medicine Center, Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Department of EndocrinologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouPeople's Republic of China
| | - Yingxiang Song
- Geriatric Medicine Center, Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Department of EndocrinologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouPeople's Republic of China
| | - Xiaohong Wu
- Geriatric Medicine Center, Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Department of EndocrinologyZhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College)HangzhouPeople's Republic of China
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Alam A, Singh SK, Kumar R. Prevalence of Organ-Specific Autoimmunity in Patients With Type 1 Diabetes Mellitus. Cureus 2023; 15:e38855. [PMID: 37303388 PMCID: PMC10256565 DOI: 10.7759/cureus.38855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
INTRODUCTION Type 1 diabetes mellitus (T1DM) is associated with other autoimmune disorders that are characterized by presence of organ-specific autoantibodies. The present study was undertaken to assess the prevalence of organ-specific autoantibodies among newly diagnosed T1DM subjects of India and to study its relationship with glutamic acid decarboxylase antibody (GADA). We also compared the clinical and biochemical parameters in GADA-positive and -negative T1DM subjects. METHODS In a hospital-based cross-sectional study, we studied 61 patients with newly diagnosed T1DM ≤ 30 years of age. T1DM was diagnosed on the basis of acute onset of osmotic symptoms with or without ketoacidosis, severe hyperglycaemia [blood glucose > 13.9 mmol/l (>250 mg/dl)] and insulin requirement from the onset of diabetes. Subjects were screened for autoimmune thyroid disease (thyroid peroxidase antibody [TPOAb]), celiac disease (tissue transglutaminase antibody [tTGAb]), and gastric autoimmunity (parietal cell antibody [PCA]). RESULTS Of the 61 subjects, more than one-third (38%) had at least one positive organ-specific autoantibody. In particular, 13 (21.3%) were found to be positive for TPOAb, nine (14.8%) were positive for tTGAb and 11 (18%) were positive for PCA. GADA was positive in 15 (25%) subjects. The frequency of TPOAb tended to be higher in patients who had GADA positivity compared with those with no circulating GADA (40% vs. 15.2%; p=0.07). Subjects positive for GADA were also more likely to be PCA positive compared with those who were GADA negative (40 vs.10.9%, p=0.02). There were no differences in frequency of diabetic ketoacidosis, body mass index, hemoglobin A1C (HbA1c), insulin requirement or fasting C-peptide in GADA-positive and -negative patients. CONCLUSION We support the recommendation for regular screening of organ-specific autoantibodies, in particular TPOAb, tTGAb and PCA in all patients with T1DM. Detection of these autoantibodies at onset may prevent complications associated with delayed diagnosis of these disorders. We also conclude that there is higher frequency of TPOAb and PCA in GADA-positive T1DM patients as compared to negative ones. However, patients with positive GADA had similar clinical and biochemical parameters compared to GADA-negative subjects. Lastly, low GADA positivity in our study cohort as compared to Western populations suggests the heterogenous nature of T1DM in the Indian population.
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Affiliation(s)
- Ahmad Alam
- Endocrinology, Diabetes and Metabolism, Rajiv Gandhi Centre for Diabetes and Endocrinology, Jawaharlal Nehru Medical College Hospital (JNMCH) Aligarh Muslim University, Aligarh, IND
- Endocrinology, Diabetes and Metabolism, Department of Endocrinology and Metabolism, Institute of Medical Sciences (IMS) Banaras Hindu University, Varanasi, IND
| | - Surya K Singh
- Endocrinology, Diabetes and Metabolism, Department of Endocrinology and Metabolism, Institute of Medical Sciences (IMS) Banaras Hindu University, Varanasi, IND
| | - Ritesh Kumar
- Endocrinology, Diabetes and Metabolism, Department of Endocrinology and Metabolism, Institute of Medical Sciences (IMS) Banaras Hindu University, Varanasi, IND
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Ji B, Suresh S, Bally K, Naher K, Banerji MA. Ketosis-Prone Type 2 Diabetes (Flatbush Diabetes) in Remission: A Report of Two Cases. Cureus 2022; 14:e28514. [PMID: 36185931 PMCID: PMC9514152 DOI: 10.7759/cureus.28514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/21/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is a triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration. It is a well-known manifestation of type 1 diabetes mellitus (T1DM). However, it can also be the first presentation of type 2 diabetes mellitus (T2DM). This subtype of diabetes shares the characteristics of both T1DM and T2DM and is called 'Flatbush diabetes,' also known as 'ketosis-prone T2DM.' This article highlights the importance of early identification of ketosis-prone T2DM (KPD). We describe two cases of African American men with no past medical histories who presented with unproved DKA as the first presentation of T2DM requiring initial intensive insulin therapy, which was gradually withdrawn with the addition of metformin. Both patients are currently insulin independent for more than 15 months. It is an essential clinical entity to recognize as insulin independence positively impacts the quality of life and decreases the economic burden on the health care system.
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Rojano-Toimil A, Rivera-Esteban J, Manzano-Nuñez R, Bañares J, Martinez Selva D, Gabriel-Medina P, Ferrer R, Pericàs JM, Ciudin A. When Sugar Reaches the Liver: Phenotypes of Patients with Diabetes and NAFLD. J Clin Med 2022; 11:jcm11123286. [PMID: 35743358 PMCID: PMC9225139 DOI: 10.3390/jcm11123286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 01/27/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) and non-alcoholic fatty liver disease (NAFLD) have been traditionally linked to one another. Recent studies suggest that NAFLD may be increasingly common in other types of diabetes such as type 1 diabetes (T1DM) and less frequently ketone-prone and Maturity-onset Diabetes of the Young (MODY) diabetes. In this review, we address the relationship between hyperglycemia and insulin resistance and the onset and progression of NAFLD. In addition, despite the high rate of patients with T2DM and other diabetes phenotypes that can alter liver metabolism and consequently develop steatosis, fibrosis, and cirrhosis, NALFD screening is not still implemented in the daily care routine. Incorporating a clinical algorithm created around a simple, non-invasive, cost-effective model would identify high-risk patients. The principle behind managing these patients is to improve insulin resistance and hyperglycemia states with lifestyle changes, weight loss, and new drug therapies.
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Affiliation(s)
- Alba Rojano-Toimil
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
| | - Jesús Rivera-Esteban
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Medicine Department Bellaterra, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Ramiro Manzano-Nuñez
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Juan Bañares
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - David Martinez Selva
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Spanish Network of Biomedical Research Centers, Diabetes and Metabolic Associated Disorders (CIBERdem), 28029 Madrid, Spain
| | - Pablo Gabriel-Medina
- Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (P.G.-M.); (R.F.)
- Biochemistry and Molecular Biology Department, Universitat Autònoma de Barcelona (UAB), Bellaterra, 08193 Barcelona, Spain
| | - Roser Ferrer
- Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (P.G.-M.); (R.F.)
| | - Juan M Pericàs
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Spanish Network of Biomedical Research Centers, Liver and Digestive Diseases (CIBERehd), 28801 Madrid, Spain
- Correspondence: (J.M.P.); (A.C.)
| | - Andreea Ciudin
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Medicine Department Bellaterra, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Spanish Network of Biomedical Research Centers, Diabetes and Metabolic Associated Disorders (CIBERdem), 28029 Madrid, Spain
- Correspondence: (J.M.P.); (A.C.)
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Patil SP. Atypical Diabetes and Management Considerations. Prim Care 2022; 49:225-237. [DOI: 10.1016/j.pop.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Al-Nuaimi MM, Ismail MM, Elhouni A. Was It a Case of “Flatbush Diabetes” with Severe Hypertriglyceridemia? IBNOSINA JOURNAL OF MEDICINE AND BIOMEDICAL SCIENCES 2022. [DOI: 10.1055/s-0042-1756686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractWe present a case of a morbidly obese 27 years male patient who was admitted with sudden onset abdominal pain and crashed into diabetic ketoacidosis as new-onset diabetes and discuss the possible etiology of this combined picture of acute pancreatitis and severe hypertriglyceridemia. Flatbush diabetes was, meanwhile, thought of due to his morbid obesity that in turn raised our suspicion of acute insulin-requiring type 2 diabetes mellitus versus T1 diabetes mellitus. Ketosis-prone diabetes or Flatbush diabetes is a syndrome in which diabetes commences with ketoacidosis in patients who are glutamic acid decarboxylase and antiislet cell antibody negative and have no known precipitating causes. They are usually middle-aged, overweight, or mildly obese, and in many reports, they are likely to be male with a family history of type 2 diabetes mellitus; they present with new-onset severe hyperglycemia and ketosis or frank diabetic ketoacidosis. After intensive initial insulin therapy, many patients become insulin-independent and can be well controlled on diet plus oral medications or, more rarely, diet alone.
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Affiliation(s)
| | | | - Ali Elhouni
- Division of Endocrinology, Tawam Hospital, Al Ain, United Arab Emirates
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Wang Y, Lu C, Augusto Monteiro Cardoso Lopes M, Chen L, Luo Y, Wu W, Gu X. A Cross-Sectional Study of Atherosclerosis in Newly Diagnosed Patients with Ketosis-Prone Type 2 Diabetes. Diabetes Metab Syndr Obes 2022; 15:933-941. [PMID: 35370412 PMCID: PMC8965103 DOI: 10.2147/dmso.s349467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/07/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE To investigate the prevalence, clinical and metabolic characteristics of atherosclerosis (AS) in newly diagnosed patients with ketosis-prone type 2 diabetes (KPT2D) or non-ketotic type 2 diabetes (NKPT2D). PATIENTS AND METHODS About 1072 subjects with non-autoimmune new-onset diabetes were included in the cross-sectional study. Patients were classified as non-ketotic type 2 diabetes (NKPT2D, n = 662) or ketosis-prone type 2 diabetes (KPT2D, n = 410). Blood samples were collected to determine the levels of glucose, HbA1c, insulin and C-peptide. Routine liver and kidney function tests were also performed. AS was determined by vascular ultrasonography. RESULTS The levels of fasting blood glucose and HbA1c were significant higher in the KPT2D group when compared to the NKPT2D group (P<0.001). The levels of fasting C-peptide, 2 h C-peptide and HOMA-β were lower in the KPT2D group than those in NKPT2D group (P<0.001). However, no significant difference was observed for HOMA-IR between the two groups. The onset age of the patients with KPT2D was significantly lower compared to NKPT2D patients (38±13 vs 49±14, P<0.001). After adjusting age of the two groups, the KPT2D patients had a higher prevalence of AS compared to the NKPT2D patients (31.4% vs 21.1%, P=0.005). In both groups, age and gender were independent risk factors for AS, whereas estimated glomerular filtration rate (eGFR) was an independent risk factor in the NKPT2D patients and 2-h postprandial plasma glucose (2h-PPG) was an independent risk factor in the KPT2D patients. CONCLUSION AS was more prevalent in KPT2D patients compared to the NKPT2D cohort, which was independent of age and gender. These data suggest that KPT2D patients may have a higher risk of macrovascular complications compared to NKPT2D of the same age.
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Affiliation(s)
- Yuxia Wang
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First Clinical School of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Chaoyin Lu
- The First Clinical School of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- Department of Endocrinology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, Zhejiang, People’s Republic of China
| | | | - Lingqiao Chen
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First Clinical School of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Yan Luo
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First Clinical School of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Wenjun Wu
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First Clinical School of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Xuemei Gu
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- The First Clinical School of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
- Correspondence: Xuemei Gu, Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Nan Bai Xiang Road, Wenzhou, 325006, People’s Republic of China, Tel +86-577-55579385, Fax +86-577-88069555, Email
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Redondo MJ, Balasubramanyam A. Toward an Improved Classification of Type 2 Diabetes: Lessons From Research into the Heterogeneity of a Complex Disease. J Clin Endocrinol Metab 2021; 106:e4822-e4833. [PMID: 34291809 PMCID: PMC8787852 DOI: 10.1210/clinem/dgab545] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Accumulating evidence indicates that type 2 diabetes (T2D) is phenotypically heterogeneous. Defining and classifying variant forms of T2D are priorities to better understand its pathophysiology and usher clinical practice into an era of "precision diabetes." EVIDENCE ACQUISITION AND METHODS We reviewed literature related to heterogeneity of T2D over the past 5 decades and identified a range of phenotypic variants of T2D. Their descriptions expose inadequacies in current classification systems. We attempt to link phenotypically diverse forms to pathophysiology, explore investigative methods that have characterized "atypical" forms of T2D on an etiological basis, and review conceptual frameworks for an improved taxonomy. Finally, we propose future directions to achieve the goal of an etiological classification of T2D. EVIDENCE SYNTHESIS Differences among ethnic and racial groups were early observations of phenotypic heterogeneity. Investigations that uncover complex interactions of pathophysiologic pathways leading to T2D are supported by epidemiological and clinical differences between the sexes and between adult and youth-onset T2D. Approaches to an etiological classification are illustrated by investigations of atypical forms of T2D, such as monogenic diabetes and syndromes of ketosis-prone diabetes. Conceptual frameworks that accommodate heterogeneity in T2D include an overlap between known diabetes types, a "palette" model integrated with a "threshold hypothesis," and a spectrum model of atypical diabetes. CONCLUSION The heterogeneity of T2D demands an improved, etiological classification scheme. Excellent phenotypic descriptions of emerging syndromes in different populations, continued clinical and molecular investigations of atypical forms of diabetes, and useful conceptual models can be utilized to achieve this important goal.
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Affiliation(s)
- Maria J Redondo
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX 77030, USA
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Adler A, Bennett P, Colagiuri Chair S, Gregg E, Narayan KMV, Inês Schmidt M, Sobngwi E, Tajima N, Tandon N, Unwin N, Wild S, Yudkin J, Levitt N, Mohan V, Montgomery S, Nyirenda MJ, Tuomilehto J, Den Boon S, Hocking S. REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS. Diabetes Res Clin Pract 2021:108972. [PMID: 34343595 DOI: 10.1016/j.diabres.2021.108972] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").
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Affiliation(s)
| | - Peter Bennett
- Phoenix Epidemiology & Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, USA
| | | | - Edward Gregg
- Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - Eugene Sobngwi
- Faculté de Medecine et des Sciences Biomedicales et Centre de Biotechnologie, Université de Yaounde 1, Cameroon
| | - Naoko Tajima
- Jikei University School of Medicine, Tokyo, Japan
| | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | - Nigel Unwin
- Chronic Disease Research Centre, The University of the West Indies, Bridgetown, Barbados, and MRC Epidemiology Unit, University of Cambridge, UK
| | | | | | - Naomi Levitt
- Diabetic Medicine and Endocrinology, Department of Medicine at Groote Schuur Hospital and University of Cape Town, South Africa
| | | | | | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute/London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
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Waddankeri SS, Swaraj Waddankeri M, Gurushantappa Mangshetty B. Clinical and Biochemical Characteristics and Treatment Outcomes of Ketosis-Prone Diabetes: The Remission Prone Diabetes. Int J Endocrinol Metab 2021; 19:e106799. [PMID: 34149844 PMCID: PMC8198612 DOI: 10.5812/ijem.106799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/22/2020] [Accepted: 02/01/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the severe acute complications of diabetes. It has long been considered a key clinical characteristic of type 1 diabetes mellitus (T1DM) with severe and irreversible deficient insulin levels. Ketosis-prone diabetes (KPD) has pathophysiology close to T2DM but shows signs and symptoms associated with T1DM. In general, patients with ketosis-prone diabetes display elevated glucose and ketone levels; also, a higher hemoglobin A1C than conventional T2DM. OBJECTIVES The current research aimed to elucidate the clinical presentation and outline a management plan for KPD in the Indian population. METHODS The present case series is a descriptive, prospective, and observational case series on six unprovoked cases of KPD. They were managed using the standard protocol of DKA management. RESULTS The recruited cases followed a set pattern of very high insulin requirement at diagnosis. On follow-up, the insulin requirement progressively declined, and all of the cases were able to stop insulin therapy after a mean period of four weeks. None of the cases presented any organ damage at diagnosis. There was no recurrence of DKA during the two-year follow-up. All of the cases had normal liver and renal functions. Autoantibodies were negative in all of the cases. CONCLUSIONS Ketosis-prone diabetes is the most under-recognized and under-diagnosed among all types of diabetes. Its recognition is of utmost importance as the approach of its treatment varies widely from that of the conventional type of diabetes. Proper follow-up, especially in unprovoked cases of DKA with obese phenotype, could help elucidate this rare entity of KPD where insulin can be stopped and maintain normoglycemia for a substantial period without insulin.
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Affiliation(s)
- Swaraj Shrikant Waddankeri
- Department of Medicine, Division of Diabetes and Endocrinology, M R Medical College, Kalaburgi, India
- Corresponding Author: Department of Medicine, Division of Diabetes and Endocrinology, M R Medical College, Kalaburgi, India.
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de Lima Ramaldes LA, Dos Santos SS, de Sa JR, Dualib PM, Dib SA. The first series of cases of ketosis-prone type 2 diabetes (flatbush diabetes) in Brazilian adults. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:231-236. [PMID: 33905625 PMCID: PMC10065323 DOI: 10.20945/2359-3997000000329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ketosis-prone type 2 diabetes (KPD) is an emerging form of diabetes mellitus characterized by unprovoked ketoacidosis, absence of autoimmunity and beta-cell dysfunction. The KPD may improve after initial glycemic compensation and evolve to exogenous insulin independence, most cases were observed in populations with African or Hispanic backgrounds. We reviewed the literature on KPD and, to date, only one case of KPD has been described in Brazil's multi-ethnic population. A group of adult Brazilian KPD patients without autoimmunity and insulinopenia was identified for this study. We report a retrospective study of four KPD cases (3 males) evaluated in southeast Brazil, the patients were overweight or obese, age between the third and fifth decades of life, had a family history of type 2 diabetes, hyperglycemia (809.5 ± 344.2 mg/dL), acidosis (pH 7.21 ± 0.07; normal range (nr): 7.35-7.45 and bicarbonate 9.1 ± 6.2; nr: 22-26 mEq/mL), ketonuria (142.5 ± 114.4 mg/dL; nr: absence), absence of glutamic acid decarboxylase antibodies (GAD-65), and beta-cell function reserve (C-peptide 1.19 ± 0.53 ng/mL - nr: 1.1-4.4 ng/mL) on diagnosis. After glycemic compensation, there was increase of C-peptide (2.21 ± 0.41) indicating the recovery of beta-cell function and the time to insulin independence was 7.7 ± 3.5 months. They evolved after the period of glucotoxicity with insulin withdrawal and could be treated with oral antidiabetic therapy. This is the first case series of KPD described in Brazil being characterized by ketoacidosis at diagnosis, absence of autoimmunity, recovery of beta-cell function and insulin independence.
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Affiliation(s)
- Luana Aparecida de Lima Ramaldes
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil,
| | - Sarah Simaan Dos Santos
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - João Roberto de Sa
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Patrícia Médici Dualib
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Sérgio Atala Dib
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil
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Vipin VP, Zaidi G, Watson K, G Colman P, Prakash S, Agrawal S, Bhatia V, Dabadghao P, Bhatia E. High prevalence of idiopathic (islet antibody-negative) type 1 diabetes among Indian children and adolescents. Pediatr Diabetes 2021; 22:47-51. [PMID: 32558116 DOI: 10.1111/pedi.13066] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/23/2020] [Accepted: 06/10/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To study the prevalence and clinical characteristics of islet antibody-negative (idiopathic) type 1 diabetes mellitus (T1DM) among Indian children and adolescents at the time of diagnosis of illness. METHODS In a hospital-based cross-sectional study, we studied 110 patients with T1DM aged ≤18 years. This included 61 patients with duration of diabetes ≤2 weeks (mean ± SD age of onset 9.9 ± 4.4 years) and 49 patients with duration 2 to 12 weeks. Antibodies against GAD65 (GADA), IA-2 (IA-2A) and zinc transporter 8 (ZnT8A), detected by radio-binding assay, were measured in all patients. Insulin autoantibody (IAA) was measured only in subjects with duration ≤2 weeks, using a competitive radio-binding assay. RESULTS The prevalence of GADA, IA-2A, and ZnT8A was 53%, 34%, and 29% respectively, while IAA (measured in 61 patients) was detected in 31%. All four antibodies were absent in 17 of 61 (28%) patients. The prevalence of islet antibody-negative patients was similar among both sexes and in children with onset younger and older than 10 years. ZnT8A was the only antibody detected in four patients, and its measurement resulted in 6% reduction in islet antibody-negative patients. Patients with idiopathic T1DM did not differ in their clinical features or fasting plasma C-peptide at the onset and after follow-up of 1 year. Compared with idiopathic T1DM, antibody-positive patients had an increased allele frequency of HLA DRB1*0301 (46% vs 14%, OR = 5.10 [confidence interval = 1.61-16.16], P = .003). CONCLUSION Nearly 30% of Indian patients were negative for all islet antibodies at the onset of T1DM. Patients with idiopathic T1DM had similar clinical features to antibody-positive subjects.
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Affiliation(s)
- Valam Puthussery Vipin
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ghazala Zaidi
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kelly Watson
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Peter G Colman
- Department of Medical Genetics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Swayam Prakash
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Suraksha Agrawal
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Vijayalakshmi Bhatia
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Preeti Dabadghao
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Eesh Bhatia
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Ye S, Ran H, Zhang H, Wu H, Li W, Du S, Su Q. Elevated Serum Triglycerides are Associated with Ketosis-Prone Type 2 Diabetes in Young Individuals. Diabetes Metab Syndr Obes 2021; 14:497-504. [PMID: 33568926 PMCID: PMC7869714 DOI: 10.2147/dmso.s296085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/20/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Ketosis-prone type 2 diabetes (KPT2D) is increasingly recognized in young adults. However, the role of blood lipids in KPT2D, especially serum triglycerides (TGs), is not yet clearly understood. PATIENTS AND METHODS We retrospectively evaluated 409 young patients diagnosed with KPT2D or classical type 2 diabetes (T2D) attending an academic tertiary hospital. Clinical characteristics and laboratory findings were compared between KPT2D and T2D patients. ANOVA or a non-parametric test analyses were used to evaluate differences in clinical characteristics and laboratory findings. Multivariate regression analyses and stratified analyses were used to further investigate differences in serum TGs levels between KPT2D and T2D individuals. RESULTS KPT2D is a subtype of T2D with traits of overweight or obesity. However, hyperglycemia and impaired β-cell functions were more severe in KPT2D patients. Serum TGs levels were significantly higher (P = 0.0003) in KPT2D individuals. Furthermore, the proportion of very high serum TGs levels was 6-fold higher (P < 0.0001) in KPT2D than in T2D patients. Elevated serum TGs were associated with young KPT2D patients. CONCLUSION Lifestyle changes as well as lipid-lowering treatments might be effective in lowering the incidence of ketosis as well as stabilizing disease progression.
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Affiliation(s)
- Shu Ye
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
| | - Hui Ran
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
| | - Hongmei Zhang
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
| | - Hui Wu
- Department of Endocrinology, Zhejiang Provincial People’s Hospital, Hangzhou Medical College, Hangzhou, 310014, People’s Republic of China
| | - Wen Li
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
| | - Shichun Du
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
- Correspondence: Shichun Du Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Kong Jiang Road 1665#, Shanghai, 200092, People’s Republic of China Email
| | - Qing Su
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
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Abstract
An etiologically based classification of diabetes is needed to account for the heterogeneity of type 1 and type 2 diabetes (T1D and T2D) and emerging forms of diabetes worldwide. It may be productive for both classification and clinical discovery to consider variant forms of diabetes as a spectrum. Maturity onset diabetes of youth and neonatal diabetes serve as models for etiologically defined, rare forms of diabetes in the spectrum. Ketosis-prone diabetes is a model for more complex forms, amenable to phenotypic dissection. Bioinformatic approaches such as clustering analyses of large datasets and multi-omics investigations of rare and atypical phenotypes are promising avenues to explore and define new subgroups of diabetes.
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Affiliation(s)
- Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, Texas 77030, USA;
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Vellanki P, Stefanovski D, Anzola II, Smiley DD, Peng L, Umpierrez GE. Long-term changes in carbohydrate tolerance, insulin secretion and action in African-American patients with obesity and history of hyperglycemic crises. BMJ Open Diabetes Res Care 2020; 8:8/1/e001062. [PMID: 32475838 PMCID: PMC7265016 DOI: 10.1136/bmjdrc-2019-001062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/31/2020] [Accepted: 05/01/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Many African-Americans (AA) with obesity with newly diagnosed diabetes presenting with diabetic ketoacidosis (DKA) or severe hyperglycemia (SH) discontinue insulin therapy and achieve near-normoglycemia remission (hemoglobin A1c (HbA1c) <7%, fasting blood glucose (FBG) <130 mg/dL) and able to be managed on oral antidiabetic agents (OAD) during follow-up. Using combined data from two randomized controlled trials, we assessed long-term carbohydrate tolerance and changes in insulin sensitivity and insulin secretion. RESEARCH DESIGN AND METHODS Seventy-five participants with DKA (n=33) and SH (n=42) underwent 2-hour 75 g oral glucose tolerance test (OGTT) after insulin discontinuation and every 6 months until hyperglycemia relapse (FBG ≥130 mg/dL, HbA1c >7% or two random BG ≥180 mg/dL) while treated with OAD (metformin, sitagliptin or pioglitazone) or placebo. Glucose tolerance status was defined as per the American Diabetes Association. Sensitivity index (Si) was calculated by oral minimal model, insulin secretion as the incremental area under the curve of insulin (IncreAUCi) and disposition index (DI) as Si×IncreAUCi. RESULTS During remission, OGTT showed normal glucose tolerance (NGT) (n=9 (12%)), prediabetes (n=34 (45%)) and diabetes (n=32 (43%)). DI and Si were higher in patients with NGT versus prediabetes versus diabetes (p<0.001), while IncreAUCi was not significantly different among NGT, prediabetes and diabetes (p=0.14). Achieving NGT status did not prolong near-normoglycemia remission. OAD treatment significantly prolonged hyperglycemia relapse-free survival (log-rank p=0.0012) compared with placebo and was associated with lower hyperglycemia relapse (HR: 0.45, 95% CI: (0.21 to 0.96), p=0.04). CONCLUSIONS In AA patients with obesity with history of DKA and SH, near-normoglycemia remission is associated with improved insulin secretion and action with half of patients achieving NGT or prediabetes, and only half having diabetes on OGTT. NGT and prediabetes on OGTT were not associated with prolonged hyperglycemia relapse-free survival. TRIAL REGISTRATION NUMBER NCT01099618, NCT00426413.
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Affiliation(s)
- Priyathama Vellanki
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Darko Stefanovski
- Department of Clinical Studies-New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
| | - Isabel I Anzola
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dawn D Smiley
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Limin Peng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
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Du S, Zhang H, Wu H, Ye S, Li W, Su Q. Prevalence and Gender Differences of Metabolic Syndrome in Young Ketosis-Prone Type 2 Diabetic Individuals: A Retrospective Study. Diabetes Metab Syndr Obes 2020; 13:2719-2727. [PMID: 32801818 PMCID: PMC7413718 DOI: 10.2147/dmso.s252492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/08/2020] [Indexed: 12/20/2022] Open
Abstract
PURPOSE This study aimed to identify the prevalence and gender differences of metabolic syndrome in young new-onset ketosis-prone type 2 diabetic (KPT2D) individuals. PATIENTS AND METHODS A retrospective study was conducted in Shanghai Xin Hua Hospital from 2007 to 2019. A total of 304 patients from 12 to 40 years of age with newly diagnosed diabetes presenting with ketosis were analyzed. The clinical features and laboratory results of KPT2D and type 1 diabetic (T1D) individuals were compared. Prevalence and gender differences of metabolic syndrome in the KPT2D subjects were analyzed. RESULTS The prevalence of metabolic syndrome (P < 0.0001) was significantly higher in young KPT2D than T1D subjects. The prevalence of high blood pressure (P < 0.0001), central obesity (P < 0.0001), low plasma HDL-C concentration (P = 0.045), and hypertriglyceridemia (P < 0.0001) was elevated in the KPT2D subjects compared with T1D. Male predominance (89%) was presented in the KPT2D subjects. The prevalence of metabolic syndrome (P = 0.0002) was significantly higher in young male than female KPT2D subjects. The presence of central obesity (P < 0.0001) and high blood pressure (P =0.03) was higher in male KPT2D subjects than female. The presence of serum triglyceride concentrations ≥ 2.3mmol/L was significantly higher (P = 0.011) in male KPT2D subjects than female. CONCLUSION Significantly higher prevalence of metabolic syndrome in young KPT2D patients compared with T1D patients could be an important reference for diabetic differential diagnosis. KPT2D presented a higher predominance in young males, who had higher prevalence of metabolic syndrome than young females.
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Affiliation(s)
- Shichun Du
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
| | - Hongmei Zhang
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
| | - Hui Wu
- Department of Endocrinology, Zhejiang Provincial People’s Hospital, Hangzhou Medical College, Hangzhou310014, People’s Republic of China
| | - Shu Ye
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
| | - Wen Li
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
| | - Qing Su
- Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai200092, People’s Republic of China
- Correspondence: Qing Su Department of Endocrinology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Kong Jiang Road 1665#, Shanghai200092, People’s Republic of China Tel/Fax +86 2125077538 Email
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Shidler KL, Letourneau LR, Novak LM. Uncommon Presentations of Diabetes: Zebras in the Herd. Clin Diabetes 2020; 38:78-92. [PMID: 31975755 PMCID: PMC6969666 DOI: 10.2337/cd19-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The majority of patients with diabetes are diagnosed as having either type 1 or type 2 diabetes. However, when encountered in clinical practice, some patients may not match the classic diagnostic criteria or expected clinical presentation for either type of the disease. Latent autoimmune, ketosis-prone, and monogenic diabetes are nonclassical forms of diabetes that are often misdiagnosed as either type 1 or type 2 diabetes. Recognizing the distinguishing clinical characteristics and understanding the diagnostic criteria for each will lead to appropriate treatment, facilitate personalized medicine, and improve patient outcomes.
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Affiliation(s)
- Karen L. Shidler
- North Central Indiana Area Health Education Center, Rochester, IN
| | | | - Lucia M. Novak
- Riverside Diabetes Center, Riverside Medical Associates, Riverdale, MD
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Catarino D, Silva D, Guiomar J, Ribeiro C, Ruas L, Cardoso L, Paiva I. Non-immune-mediated versus immune-mediated type 1 diabetes: diagnosis and long-term differences-retrospective analysis. Diabetol Metab Syndr 2020; 12:56. [PMID: 32647539 PMCID: PMC7336466 DOI: 10.1186/s13098-020-00563-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/25/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The American Diabetes Association proposed two subcategories for type 1 diabetes mellitus: type 1A or immune-mediated diabetes (IDM) and type 1B or idiopathic diabetes. The absence of β-cell autoimmune markers, permanent insulinopenia and prone to ketoacidosis define the second category, whose pathogenesis remains unclear. Only a minority of patients fall into this category, also designated non-immune-mediated (NIDM), which is considered by several authors similar to type 2 diabetes. The aim of this study is to evaluate differences at the diagnosis and 10 years later of two categories. METHODS Retrospective cohort study of patients with β-cell autoimmune markers performed at diagnosis and undetectable c-peptide. Were excluded patients with suspicion of another specific type of diabetes. We obtained two groups: IDM (≥ 1 positive antibody) and NIDM (negative antibodies). Age, family history, anthropometry, duration of symptoms, clinical presentation, blood glucose at admission, A1C, lipid profile, arterial hypertension, total diary insulin dose (TDID), microvascular and macrovascular complications were evaluated. Results were considered statistically significant with p < 0.05. RESULTS 37 patients, 29 with IDM and 8 patients with NIDM. The age of diagnosis of IDM group (23 years) was significantly different (p = 0.004) from the NIDM group (38.1). The body mass index (BMI) at the diagnosis did not differ significantly (p = 0.435). The duration of symptoms was longer in the NIDM (p = 0.003). The disease presentation (p = 0.744), blood glucose (p = 0.482) and HbA1c (p = 0.794) at admission and TDID at discharge (p = 0.301) did not differ significantly. Total and LDL cholesterol levels were higher in NIDM group but did not differ significantly (p = 0.585 and p = 0.579, respectively). After 10 years BMI did not differ between groups (p = 0.079). Patients with IDM showed a significantly higher HbA1c (p = 0.008) and TDID (p = 0.017). Relative to the lipid profile, there was no significant difference, however the LDL cholesterol and triglycerides were higher on the NIDM group, as the percentage of hypertension. Microvascular complications were higher in the IDM group, but no significant difference was found. CONCLUSION Patients with IDM had a poor metabolic control and higher insulin requirement. Patients with NIDM were older and showed higher cardiovascular risk, resembling a clinical phenotype of type 2 diabetes.
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Affiliation(s)
- Diana Catarino
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
| | - Diana Silva
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
| | - Joana Guiomar
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
| | - Cristina Ribeiro
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
| | - Luísa Ruas
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
| | - Luís Cardoso
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
- Medicine Faculty of Coimbra University, Coimbra, Portugal
| | - Isabel Paiva
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar e Universitário de Coimbra EPE, Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
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Abstract
RATIONALE In recent years, there are more new insights into the clinical susceptibility, pathophysiological mechanism, and progression of classification and treatment of ketosis-prone diabetes mellitus (KPDM), which was once described as Idiopathic Type 1 Diabetes, Type 1B Diabetes or Flatbush Diabetes. ketosis-prone diabetes mellitus is still a heterogeneous syndrome reported in African-American or western Sub-Sahara-African, Hispanic descendant, and recently in Asian. PATIENT CONCERNS An obese 17-year-old student was admitted to a tertiary referral hospital (teaching hospital), presenting with thirst, polyuria fatigue, and a 9 kg weight loss in the preceding two weeks. DIAGNOSES Physical examination showed body mass index (BMI) was 32.77 kg/m, arterial blood gas revealed a pH of 7.31. Serum glucose was 27.8 mmol/L with strong positive uric ketones (++++). Hemoglobin A1c (HbA1c) was 13.6%. The glucose disposal ratio (GDR) during the steady-state of euglycemic clamp test was 5.62 mg/kg/min and M value was 2.87 mg/kg/min during hyperglycemic clamp test. Those findings were sufficient to establish a diagnosis of ketosis-prone diabetes mellitus. INTERVENTIONS This obese patient with KPDM received intensive insulin therapy and fluids infusion, and during the remainder of hospitalization his insulin requirement was approximately 1.5 U per kilogram of body weight per day. Blood glucose monitoring was rigorous until the diabetic ketoacidosis under control. OUTCOMES He achieved the near-nomalglycemic remission uneventfully. At 12-month follow-up, his treatment was adjusted from insulin subcutaneous injection to oral hypoglycemic drugs. LESSON The present study of this obese adolescent with negative auto-antibodies but unprovoked diabetic ketoacidosis and partially preserved beta cell functional reserve after the acute of diabetic ketosis suggested that he has the phenotype of "A-β" KPDM. Further study of this syndrome will help illustrate the inadequacy of current classification and targeted therapies.
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Affiliation(s)
- Huiwen Tan
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu
| | - Chun Wang
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu
| | - Yerong Yu
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu
- Laboratory of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan, PR China
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Gaba R, Mehta P, Balasubramanyam A. Evaluation and management of ketosis-prone diabetes. Expert Rev Endocrinol Metab 2019; 14:43-48. [PMID: 30612498 DOI: 10.1080/17446651.2019.1561270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 12/17/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Patients presenting with diabetic ketoacidosis (DKA) who lack the classic phenotype of autoimmune type 1 diabetes have become increasingly identified in recent decades. This has led to the recognition of heterogeneous syndromes of 'ketosis-prone diabetes' (KPD). Evaluation and optimal management of KPD differs from that of 'typical' type 1 or type 2 diabetes. Awareness of these differences and a systematic approach to diagnosis and treatment can improve glycemic control and prevent both acute and chronic complications of diabetes. AREAS COVERED This article reviews the Aß classification scheme ('A' for autoantibody status and 'ß' for beta cell functional reserve) which accurately delineates subgroups of KPD, and addresses the relevance of defining these subgroups for clinical outcomes and long-term insulin dependence. Subsequently, the detailed evaluation and management of KPD patients after their index DKA episode is described. EXPERT COMMENTARY Among patients presenting with DKA, it is important to diagnose specific subgroups of KPD and not assume that they represent exclusively patients with autoimmune type 1 diabetes. The Aß classification is an accurate aid to diagnosis, and permits optimal management of the subgroups (e.g., insulin treatment for the ß- subgroups; follow-up testing and a range of treatment options for the ß+ subgroups).
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Affiliation(s)
- Ruchi Gaba
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
| | - Paras Mehta
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
| | - Ashok Balasubramanyam
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
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Abstract
PURPOSE OF REVIEW Ketosis-prone diabetes or Flatbush diabetes has been widely recognized as a clinical entity since 1984. Most of the early clinical studies focused on African American or Afro-Caribbean individuals. It is now being recognized as an important clinical entity in sub-Saharan Africans, Asian and Indian populations, and Hispanic populations. Major questions remain as to its pathogenesis and whether it is a unique type of diabetes or a subset of more severe type 2 diabetes with greater loss of insulin action in target tissues. This review summarizes the main clinical and mechanistic studies to improve the understanding of ketosis-prone (Flatbush) diabetes. RECENT FINDINGS Little data are available on the magnitude of KPD in the different susceptible populations. It is relatively common in black populations. KPD is defined as a syndrome in which diabetes commences with ketoacidosis in individuals who are GAD and anti-islet cell antibody negative and have no known precipitating causes. The patients present during middle age, are overweight or mildly obese, and in many reports are more likely to be male. After intensive initial insulin therapy, many patients become insulin independent and can be well controlled on diet alone or diet plus oral medications. The clinical course of KPD is like that of patients with type 2 diabetes rather than that of type 1 diabetes. Little differences are found in the clinical characteristics and clinical outcomes between patients presenting with KPD and those presenting with severe hyperglycemia with no ketoacidosis. The mechanisms responsible for the development of ketosis-prone diabetes as well its remission remain unknown.
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Affiliation(s)
- Harold E. Lebovitz
- 0000 0001 0693 2202grid.262863.bDivision of Endocrinology, Department of Medicine, State University of New York Health Science Center at Brooklyn, 450 Clarkson Ave., Box 1205, Brooklyn, NY 11203 USA
| | - Mary Ann Banerji
- 0000 0001 0693 2202grid.262863.bDivision of Endocrinology, Department of Medicine, State University of New York Health Science Center at Brooklyn, 450 Clarkson Ave., Box 1205, Brooklyn, NY 11203 USA
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Prevalence and clinical characteristics of non-alcoholic fatty liver disease in newly diagnosed patients with ketosis-onset diabetes. DIABETES & METABOLISM 2018; 44:437-443. [PMID: 29631765 DOI: 10.1016/j.diabet.2018.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 01/28/2018] [Accepted: 03/06/2018] [Indexed: 02/06/2023]
Abstract
AIM As the prevalence and clinical characteristics of non-alcoholic fatty liver disease (NAFLD) are still unknown in ketosis-onset diabetes, the present study compared the characteristics of NAFLD in type 1 diabetes (T1D), ketosis-onset and non-ketotic type 2 diabetes (T2D) patients. METHODS This cross-sectional study was performed with newly diagnosed Chinese patients with diabetes, including 39 T1D, 165 ketosis-onset and 173 non-ketotic T2D, with 30 non-diabetics included as controls. NAFLD was determined by hepatic ultrasonography, then its clinical features were analyzed and its associated risk factors evaluated. RESULTS NAFLD prevalence in patients with ketosis-onset diabetes (61.8%) was significantly higher than in controls (23.3%; P=0.003) and in T1D patients (15.4%; P<0.001). However, there was no difference in prevalence between ketosis-onset and non-ketotic T2D patients (52.6%; P=0.229), although BMI and alanine aminotransferase (ALT) proved to be independent risk factors for the presence of NAFLD in both these groups whereas, in T1D patients, serum uric acid levels were independent risk factors. CONCLUSION NAFLD prevalence and risk factors in ketosis-onset diabetes were similar to those in non-ketotic T2D, but different from those in T1D. These data provide further evidence that ketosis-onset diabetes should be classified as a subtype of T2D rather than idiopathic T1D.
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Vellanki P, Umpierrez GE. DIABETIC KETOACIDOSIS: A COMMON DEBUT OF DIABETES AMONG AFRICAN AMERICANS WITH TYPE 2 DIABETES. Endocr Pract 2017; 23:971-978. [PMID: 28534682 DOI: 10.4158/ep161679.ra] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE More than half of African Americans (AA) with a new diagnosis of diabetic ketoacidosis have clinical and metabolic features of type 2 diabetes during follow-up. This particular presentation of diabetes has been termed as ketosis-prone type 2 diabetes (KPDM) or atypical diabetes. METHODS We review the epidemiology, diagnosis, pathophysiology, and acute and long-term management of AA with KPDM and compare these similarities to patients with type 2 diabetes. RESULTS In contrast to the long-term insulin requirement of auto-immune type 1 diabetes, patients with KPDM are able to discontinue insulin after a few months of therapy and maintain acceptable glycemic control for many years on either diet or oral agents. Patients with KPDM have significant impairment of both insulin secretion and insulin action at presentation; however, at the time of near-normoglycemia remission, insulin secretion and action improve to levels similar to hyperglycemic patients with ketosis-resistant type 2 diabetes. In the long term, however, patients with KPDM have a decline in β-cell function similar to patients with type 2 diabetes. Recent studies indicate that treatment with metformin and dipeptidyl peptidase-4 inhibitors can prolong the period of near-normoglycemia remission for several years compared to placebo therapy. CONCLUSION KPDM is a unique but common presentation of newly diagnosed African Americans with type 2 diabetes. ABBREVIATIONS A(+/-) = auto-antibody positive/negative AA = African Americans DKA = diabetic ketoacidosis FFA = free fatty acids G6PD = glucose-6-phosphate dehydrogenase GAD-65 = 65-kDA glutamic acid decarboxylase HBA1c = glycated hemoglobin A1c HHV8 = human herpes virus 8 HLA = human leukocyte antigen KPDM = ketosis-prone type 2 diabetes.
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26
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Levitt Katz LE. C-Peptide and 24-Hour Urinary C-Peptide as Markers to Help Classify Types of Childhood Diabetes. Horm Res Paediatr 2016; 84:62-4. [PMID: 26045021 DOI: 10.1159/000430094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Lorraine E Levitt Katz
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa., USA
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Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism 2016; 65:507-21. [PMID: 26975543 DOI: 10.1016/j.metabol.2015.12.007] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/10/2015] [Accepted: 12/16/2015] [Indexed: 12/11/2022]
Abstract
The prognosis of diabetic ketoacidosis has undergone incredibly remarkable evolution since the discovery of insulin nearly a century ago. The incidence and economic burden of diabetic ketoacidosis have continued to rise but its mortality has decreased to less than 1% in good centers. Improved outcome is attributable to a better understanding of the pathophysiology of the disease and widespread application of treatment guidelines. In this review, we present the changes that have occurred over the years, highlighting the evidence behind the recommendations that have improved outcome. We begin with a discussion of the precipitants and pathogenesis of DKA as a prelude to understanding the rationale for the recommendations. A brief review of ketosis-prone type 2 diabetes, an update relating to the diagnosis of DKA and a future perspective are also provided.
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Affiliation(s)
- Ebenezer A Nyenwe
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Ave., Suite 300A, Memphis, TN 38163.
| | - Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Ave., Suite 300A, Memphis, TN 38163
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Adejumo BI, Dimkpa U, Ewenighi CO, Emmanuel AM, Odionyenma UC, Uchuno GA, Omosor KI, Aghedo FI. The Risk of Islet Cell and Insulin Autoantibodies and Their Predictive Strength as Markers of Type-1 Diabetes in a Cross-Section of Nigerian Population. Health (London) 2016. [DOI: 10.4236/health.2016.812125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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29
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Du S, Yang X, Shi D, Su Q. Comparison between New-Onset and Old-Diagnosed Type 2 Diabetes with Ketosis in Rural Regions of China. Int J Endocrinol 2016; 2016:3010243. [PMID: 26966435 PMCID: PMC4757694 DOI: 10.1155/2016/3010243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/30/2015] [Accepted: 01/12/2016] [Indexed: 01/19/2023] Open
Abstract
Objectives. Type 2 diabetes (T2D) with ketosis was common because of late diagnosis and lacking adequate treatment in rural regions of China. This study aimed to provide the data of T2D with ketosis among inpatients in a south-west border city of China. Methods. Data of 371 patients of T2D with ketosis who were hospitalized between January 2011 and July 2015 in Baoshan People's Hospital, Yunnan, China, were analyzed. New-onset and old-diagnosed T2D patients presenting with ketosis were compared according to clinical characteristics, laboratory results, and chronic diabetic complications. Results. Overall, the blood glucose control was poor in our study subjects. Male predominated in both groups (male prevalence was 68% in new-onset and 64% in old-diagnosed groups). Overweight and obesity accounted for 50% in new-onset and 46% in old-diagnosed cases. Inducements of ketosis were 13.8% in new-onset and 38.7% in old-diagnosed patients. Infections were the first inducements in both groups. The prevalence of chronic complications of diabetes was common in both groups. Conclusions. More medical supports were needed for the early detection and adequate treatment of diabetes in rural areas of China.
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Affiliation(s)
- Shichun Du
- Department of Endocrinology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Xia Yang
- Department of Endocrinology, Baoshan People's Hospital, Yunnan 678000, China
| | - Degang Shi
- Department of Endocrinology, Baoshan People's Hospital, Yunnan 678000, China
| | - Qing Su
- Department of Endocrinology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
- *Qing Su:
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30
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Ayed S, Bouguerba A, Ahmed P, Barchazs J, Boukari M, Goldgran-Toledano D, Bornstain C, Vincent F. Les pièges de l’acidocétose diabétique. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1113-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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31
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Dean HJ, Sellers EA. Children have type 2 diabetes too: an historical perspective. Biochem Cell Biol 2015; 93:425-9. [DOI: 10.1139/bcb-2014-0152] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Prior to 1985, type 2 diabetes was a disease of adults. Simultaneously with the global epidemic of childhood obesity, type 2 diabetes has increased in children. Initially, the presentation of small case series of type 2 diabetes in children was met with skepticism. As the number and size of the case series grew and the first long-term outcomes of end-stage complications in young adults appeared in the literature, the international community took notice with guarded interest. Type 2 diabetes disproportionately affects the children of specific ethnic groups and from disadvantaged socioeconomic environments, especially Indigenous populations. The past decade has seen unprecedented intense global interest in the etiology, treatment, and prevention of type 2 diabetes in children.
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Affiliation(s)
- Heather J. Dean
- Department of Pediatrics and Child Health, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0Z2, Canada
- Department of Pediatrics and Child Health, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0Z2, Canada
| | - Elizabeth A.C. Sellers
- Department of Pediatrics and Child Health, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0Z2, Canada
- Department of Pediatrics and Child Health, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3E 0Z2, Canada
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32
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Zhang M, Li Y, Cui W, Yang P, Li H, Sheng C, Cheng X, Qu S. THE CLINICAL AND METABOLIC CHARACTERISTICS OF YOUNG-ONSET KETOSIS-PRONE TYPE 2 DIABETES IN CHINA. Endocr Pract 2015; 21:1364-71. [PMID: 26372299 DOI: 10.4158/ep15778.or] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the prevalence and clinical characteristics of ketosis-prone type 2 diabetes (KPD) in Chinese patients with young-onset diabetes. METHODS A total of 238 young diabetic patients were recruited from our inpatient department from January 1, 2012, to December 28, 2014. KPD was defined as diabetes without precipitating illness and with the presence of ketosis or diabetic ketoacidosis in the absence of autoantibodies at the time of diagnosis. We reviewed the clinical characteristics and disease progression of this group of patients. RESULTS Eighteen patients fulfilled the criteria for KPD, and the prevalence of patients with KPD was 7.6%. The mean (SD) age of the KPD group at the time of diagnosis of diabetes was 27.6 (4.85) years, and these patients were predominantly male (male to female ratio, 8:1) and had a high proportion of obesity and new-onset diabetes and a strong family history of diabetes. β-Cell function in the KPD group was intermediate between type 1 and type 2 diabetes. Patients with KPD had the highest levels of glycated hemoglobin, triglycerides, total cholesterol, and free fatty acids and the lowest levels of high-density lipoprotein. After 3 to 12 months of follow-up, 17 of 18 patients with KPD (94.4%) were able to discontinue insulin therapy, and 11 patients (61.1%) were managed with diet or exercise alone. CONCLUSION KPD patients accounted for 7.6% of the diabetic patients requiring admission to a large urban hospital in China, with an age of onset of diabetes of ≤35 years. These patients are more likely to be male, have abnormal lipid metabolism, and have more reversible β-cell dysfunction.
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Wang X, Tan H. Male predominance in ketosis-prone diabetes mellitus. Biomed Rep 2015; 3:439-442. [PMID: 26171144 DOI: 10.3892/br.2015.461] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 04/22/2015] [Indexed: 02/05/2023] Open
Abstract
The incidence of ketosis-prone diabetes mellitus (KPDM) shows a higher prevalence in men. The clear male predominance of this syndrome and its underlying pathogenesis mechanisms are unclear. KPDM, once described as atypical diabetes mellitus, idiopathetic type 1 diabetes (type 1B diabetes) and flatbush diabetes, is an uncommon form of diabetes characterized by severe reversible insulin deficiency. KPDM was first described and mostly observed in males of African-American descent and recently in Asian populations, including Japanese and Chinese. Patients with KPDM often present acutely with diabetic ketoacidosis without any immunological autoantibody to islet antigens of classic type 1 diabetes but demonstrate clinical and metabolic features of type 2 diabetes. Accumulating data indicated that gender-related body fat distribution, hormonal and genetic factors are associated with the diabetic process and the human glucose homeostasis and metabolism. A controversial question is whether and to what degree those factors contribute to the phenomenon of male predominance in KPDM. The present review focuses on the role of gender hormones and other potential precipitating factors in explaining the male predominance in KPDM patients.
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Affiliation(s)
- Xiaohao Wang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
| | - Huiwen Tan
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China
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Abstract
This article highlights the difficulties in creating a definitive classification of diabetes mellitus in the absence of a complete understanding of the pathogenesis of the major forms. This brief review shows the evolving nature of the classification of diabetes mellitus. No classification scheme is ideal, and all have some overlap and inconsistencies. The only diabetes in which it is possible to accurately diagnose by DNA sequencing, monogenic diabetes, remains undiagnosed in more than 90% of the individuals who have diabetes caused by one of the known gene mutations. The point of classification, or taxonomy, of disease, should be to give insight into both pathogenesis and treatment. It remains a source of frustration that all schemes of diabetes mellitus continue to fall short of this goal.
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Affiliation(s)
- Celeste C Thomas
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 5841 South Maryland Avenue, MC 1027, Chicago, IL 60637, USA.
| | - Louis H Philipson
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 5841 South Maryland Avenue, MC 1027, Chicago, IL 60637, USA; Department of Pediatrics, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 900 East 57th Street, Chicago, IL 60637, USA
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35
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Zeitler P, Fu J, Tandon N, Nadeau K, Urakami T, Barrett T, Maahs D. ISPAD Clinical Practice Consensus Guidelines 2014. Type 2 diabetes in the child and adolescent. Pediatr Diabetes 2014; 15 Suppl 20:26-46. [PMID: 25182306 DOI: 10.1111/pedi.12179] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Affiliation(s)
- Phil Zeitler
- The Children's Hospital Colorado, Aurora, CO, USA
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Lima-Martínez MM, Guerra-Alcalá E, Contreras M, Nastasi J, Noble JA, Polychronakos C. One year remission of type 1 diabetes mellitus in a patient treated with sitagliptin. Endocrinol Diabetes Metab Case Rep 2014; 2014:140072. [PMID: 25332771 PMCID: PMC4190822 DOI: 10.1530/edm-14-0072] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 09/16/2014] [Indexed: 12/26/2022] Open
Abstract
Type 1 diabetes mellitus (T1DM) is a chronic disease characterized by the autoimmune destruction of pancreatic β-cells. This paper describes the case of a 19-year-old male patient who presented with glutamic acid decarboxylase (GAD) antibody positive and diabetic ketoacidosis, which mandated intensive insulin treatment. Once the ketoacidosis was controlled, an oral dose of 100 mg of sitagliptin was administered once a day. Ketoacidosis was managed by insulin and insulin daily requirement began to dwindle after one month, until its complete withdrawal at 8 weeks, when partial remission was reached. The patient has now remained on sitagliptin treatment alone for a year, without requiring insulin. The benefit observed with this medication is possibly associated with its immunological effects. Inhibition of dipeptidyl peptidase 4 in animal models deregulates the Th1 immune response, increases secretion of Th2 cytokines, activates CD4+CD25+FoxP3+ regulatory T-cells, and prevents IL17 production.
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Affiliation(s)
- Marcos M Lima-Martínez
- Departamento de Ciencias Fisiológicas , Universidad de Oriente , Ciudad Bolívar , Venezuela ; Unidad de Endocrinología, Diabetes, Metabolismo y Nutrición , Anexo A. Centro Médico Orinoco , Avenida Siegart, Ciudad Bolívar, 8001 Venezuela
| | | | | | - José Nastasi
- Servicio de Genética Médica , Universidad de Oriente , Ciudad Bolívar , Venezuela
| | - Janelle A Noble
- Children's Hospital Oakland Research Institute , Oakland, California , USA
| | - Constantin Polychronakos
- Departments of Paediatrics and Human Genetics , McGill University Health Centre , Montreal, Quebec , Canada
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Babiker T, Chakera AJ, Shepherd M, Hattersley AT. A diagnostic approach for defining idiopathic remitting diabetes: a retrospective cohort study. BMC Endocr Disord 2014; 14:45. [PMID: 24909320 PMCID: PMC4064804 DOI: 10.1186/1472-6823-14-45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 05/28/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND 11 patients were referred to our Molecular Genetics Department at the Royal Devon and Exeter Hospital between 2000-2012 with a physician's diagnosis of remitting diabetes. Our aim was to identify patients with remitting diabetes whose clinical presentation is not explained by any known aetiology of diabetes. METHODS We obtained longitudinal clinical data on all 11 patients from the hospital records. All patients were aged between 0.5 and 35 years at diagnosis. We applied clinical criteria derived from the literature to establish 1) definite diabetes, 2) diabetes initially severe-requiring treatment with insulin, 3) remission of diabetes, and 4) exclusion of known causes of remitting diabetes. RESULTS 10 out of 11 patients had an alternative explanation for their remission or a clear diagnosis was not identified. We identified a single patient with idiopathic remitting diabetes using these criteria. The patient was a white Caucasian female diagnosed aged 15 with symptoms of diabetes, laboratory glucose of 21.2 mmol/L and HbA1c 134 mmol/mol. Her BMI was 23.6 kg/m2. She was treated with basal bolus insulin but discontinued two years after diagnosis due to hypoglycaemia. 13 years post diagnosis, she had a normal oral glucose tolerance test during pregnancy (fasting glucose 4.5 mmol/L, 2 hr glucose 4.8 mmol/L) and an HbA1c of 30 mmol/mol. This patient does not appear to have Type 1 or Type 2 diabetes, and furthermore does not fit into current classifications of diabetes. CONCLUSIONS Idiopathic remitting diabetes is rare but does exist. Strict clinical criteria are important to ensure patients have a robust clinical diagnosis. Identification of more patients with idiopathic remitting diabetes will enable further study of the clinical course of this syndrome. Applying these strict criteria will allow the identification of patients with remitting diabetes to assess its aetiology.
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Affiliation(s)
- Tarig Babiker
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK
| | - Ali J Chakera
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK
| | - Maggie Shepherd
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK
| | - Andrew T Hattersley
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK
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Abstract
Diabetes is a much more heterogeneous disease than the present subdivision into types 1 and 2 assumes; type 1 and type 2 diabetes probably represent extremes on a range of diabetic disorders. Both type 1 and type 2 diabetes seem to result from a collision between genes and environment. Although genetic predisposition establishes susceptibility, rapid changes in the environment (ie, lifestyle factors) are the most probable explanation for the increase in incidence of both forms of diabetes. Many patients have genetic predispositions to both forms of diabetes, resulting in hybrid forms of diabetes (eg, latent autoimmune diabetes in adults). Obesity is a strong modifier of diabetes risk, and can account for not only a large proportion of the epidemic of type 2 diabetes in Asia but also the ever-increasing number of adolescents with type 2 diabetes. With improved characterisation of patients with diabetes, the range of diabetic subgroups will become even more diverse in the future.
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Affiliation(s)
- Tiinamaija Tuomi
- Department of Medicine, Helsinki University Hospital, Helsinki, Finland; Folkhälsan Research Center, Helsinki, Finland; Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland
| | - Nicola Santoro
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Sonia Caprio
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Mengyin Cai
- Department of Endocrinology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianping Weng
- Department of Endocrinology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Leif Groop
- Department of Clinical Sciences, Diabetes and Endocrinology, Lund University, Malmö, Sweden; Institute for Molecular Medicine Finland (FIMM), University of Helsinki, Helsinki, Finland.
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Xie XJ, Hu Y, Cheng C, Feng TT, He K, Mao XM. Should diabetic ketosis without acidosis be included in ketosis-prone type 2 diabetes mellitus? Diabetes Metab Res Rev 2014; 30:54-9. [PMID: 24038858 DOI: 10.1002/dmrr.2448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 07/31/2013] [Accepted: 08/19/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND The incidence of ketosis-prone type 2 diabetes is very low except for people of sub-Saharan African origin and African Americans. However, there also are some type 2 diabetes patients with diabetic ketosis without acidosis (DKWA). We question whether DKWA should be included as a subtype of ketosis-prone type 2 diabetes mellitus and compared the clinical characteristics of DKWA and diabetic ketoacidosis (DKA) patients. METHODS The study population consisted of 594 consecutive unrelated Chinese inpatients with newly diagnosed type 2 diabetes. Demographic and clinical characteristics (age, gender, family history of diabetes, body mass index, blood pressure and plasma lipid parameters) were recorded. The patients were divided into ketosis-resistant diabetes (KRD), DKWA and DKA groups on the basis of urinary ketones, blood pH and bicarbonate levels. The blood glucose and c-peptide levels of the patients were also evaluated. RESULTS The prevalence of KRD, DKWA and DKA were 78.33%, 19.72% and 1.95%, respectively, in the study population. The clinical characteristics of patients with DKWA group patients were similar to those with DKA, except that DKA patients had higher blood glucose and deteriorated β cell function. CONCLUSIONS Diabetic ketosis without acidosis and DKA patients share similar clinical characteristics; DKWA should be considered ketosis-prone type 2 diabetes. Therefore, the prevalence of ketosis-prone type 2 diabetes might be underestimated.
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Affiliation(s)
- Xiao-Jing Xie
- Department of Endocrinology, Nanjing First Hospital Affiliated to Nanjing Medical University, 68 ChangLe St., Nanjing, China
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Roy MS, Janal MN, Crosby J, Donnelly R. Inflammatory biomarkers and progression of diabetic retinopathy in African Americans with type 1 diabetes. Invest Ophthalmol Vis Sci 2013; 54:5471-80. [PMID: 23847308 DOI: 10.1167/iovs.13-12212] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE We examined whether baseline plasma levels of markers of inflammation and endothelial dysfunction are associated with the incidence of diabetic retinopathy (DR) in African Americans with type 1 insulin-dependent diabetes mellitus (T1DM). METHODS At baseline and follow-up examinations, detailed ocular examination, structured clinical interview, venous blood specimens, and masked grading of seven standard field retinal photographs were obtained. Baseline plasma levels of 28 inflammatory biomarkers, measured using multiplex bead analysis system, were measured in the participants. RESULTS After adjusting for age, glycemic control, and other potential confounders, baseline plasma levels of E-selectin were associated significantly with progression of DR, E-selectin and tumor necrosis factor-α (TNF-α) levels with incidence of proliferative DR (PDR), and soluble intercellular adhesion molecule-1 (sICAM-1) and TNF-α levels with incidence of macular edema (ME). CONCLUSIONS In African Americans with T1DM, inflammation and endothelial dysfunction precede the development of DR, thus supporting the notion that inflammation may influence progression/incidence of disease.
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Affiliation(s)
- Monique S Roy
- Institute of Ophthalmology and Visual Science, University of Medicine and Dentistry, New Jersey Medical School, 90 Bergen Street, Room 6164, Newark, NJ 07101-1709, USA.
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Affiliation(s)
- Maria A. Ramos-Roman
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shawn C. Burgess
- Department of Pharmacology, The University of Texas Southwestern Medical Center, Dallas, Texas
- Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeffrey D. Browning
- Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
- Advanced Imaging Research Center, The University of Texas Southwestern Medical Center, Dallas, Texas
- Corresponding author: Jeffrey D. Browning,
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Li LX, Zhao CC, Ren Y, Tu YF, Lu JX, Wu X, Zhang WX, Zhu JA, Li MF, Yu LB, Bao YQ, Jia WP. Prevalence and clinical characteristics of carotid atherosclerosis in newly diagnosed patients with ketosis-onset diabetes: a cross-sectional study. Cardiovasc Diabetol 2013; 12:18. [PMID: 23324539 PMCID: PMC3583071 DOI: 10.1186/1475-2840-12-18] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 01/11/2013] [Indexed: 11/10/2022] Open
Abstract
Background The features of carotid atherosclerosis in ketosis-onset diabetes have not been investigated. Our aim was to evaluate the prevalence and clinical characteristics of carotid atherosclerosis in newly diagnosed Chinese diabetic patients with ketosis but without islet-associated autoantibodies. Methods In total, 423 newly diagnosed Chinese patients with diabetes including 208 ketosis-onset diabetics without islet-associated autoantibodies, 215 non-ketotic type 2 diabetics and 79 control subjects without diabetes were studied. Carotid atherosclerosis was defined as the presence of atherosclerotic plaques in any of the carotid vessel segments. Carotid intima-media thickness (CIMT), carotid atherosclerotic plaque formation and stenosis were assessed and compared among the three groups based on Doppler ultrasound examination. The clinical features of carotid atherosclerotic lesions were analysed, and the risk factors associated with carotid atherosclerosis were evaluated using binary logistic regression in patients with diabetes. Results The prevalence of carotid atherosclerosis was significantly higher in the ketosis-onset diabetic group (30.80%) than in the control group (15.2%, p=0.020) after adjusting for age- and sex-related differences, but no significant difference was observed in comparison to the non-ketotic diabetic group (35.8%, p=0.487). The mean CIMT of the ketosis-onset diabetics (0.70±0.20 mm) was markedly higher than that of the control subjects (0.57±0.08 mm, p<0.001), but no significant difference was found compared with the non-ketotic type 2 diabetics (0.73±0.19 mm, p=0.582) after controlling for differences in age and sex. In both the ketosis-onset and the non-ketotic diabetes, the prevalence of carotid atherosclerosis was markedly increased with age (both p<0.001) after controlling for sex, but no sex difference was observed (p=0.479 and p=0.707, respectively) after controlling for age. In the ketosis-onset diabetics, the presence of carotid atherosclerosis was significantly associated with age, hypertension, low-density lipoprotein cholesterol and mean CIMT. Conclusions The prevalence and risk of carotid atherosclerosis were significantly higher in the ketosis-onset diabetics than in the control subjects but similar to that in the non-ketotic type 2 diabetics. The characteristics of carotid atherosclerotic lesions in the ketosis-onset diabetics resembled those in the non-ketotic type 2 diabetics. Our findings support the classification of ketosis-onset diabetes as a subtype of type 2 diabetes.
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Affiliation(s)
- Lian-Xi Li
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China.
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Vaibhav A, Mathai M, Gorman S. Atypical diabetes in children: ketosis-prone type 2 diabetes. BMJ Case Rep 2013; 2013:bcr-2012-007704. [PMID: 23302548 DOI: 10.1136/bcr-2012-007704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Ketosis-prone type 2 diabetes mellitus also known as atypical or flatbush diabetes is being increasingly recognised worldwide. These patients are typically obese, middle-aged men with a strong family history of type 2 diabetes. The aetiology and pathophysiological mechanism is still unclear but some initial research suggests that patients with ketosis-prone type 2 diabetes have a unique predisposition to glucose desensitisation. These patients have negative autoantibodies typically associated with type 1 diabetes but have shown to have human leucocyte antigen (HLA) positivity. At initial presentation, there is an impairment of both insulin secretion and action. β Cell function and insulin sensitivity can be markedly improved by initiating aggressive diabetes management to allow for discontinuation of insulin therapy within a few months of treatment. These patients can be maintained on oral hypoglycaemic agents and insulin therapy can be safely discontinued after few months depending on their β cell function.
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Affiliation(s)
- Atul Vaibhav
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, West Yorkshire, UK.
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Liu B, Yu C, Li Q, Li L. Ketosis-onset diabetes and ketosis-prone diabetes: same or not? Int J Endocrinol 2013; 2013:821403. [PMID: 23710177 PMCID: PMC3655588 DOI: 10.1155/2013/821403] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 11/17/2022] Open
Abstract
Objective. To compare clinical characteristics, immunological markers, and β -cell functions of 4 subgroups ("A β " classification system) of ketosis-onset diabetes and ketosis prone diabetes patients without known diabetes, presenting with ketosis or diabetic ketoacidosis (DKA) and admitted to our department from March 2011 to December 2011 in China, with 50 healthy persons as control group. Results. β -cell functional reserve was preserved in 63.52% of patients. In almost each subgroup (except A- β - subgroup of ketosis prone group), male patients were more than female ones. The age of the majority of patients in ketosis prone group was older than that of ketosis-onset group, except A- β - subgroup of ketosis prone group. The durations from the patient first time ketosis or DKA onset to admitting to the hospital have significant difference, which were much longer for the ketosis prone group except the A+ β + subgroup. BMI has no significant difference among subgroups. FPG of ketosis prone group was lower than that of A- β + subgroup and A+ β + subgroup in ketosis-onset group. A- β - subgroup and A+ β + subgroup of ketosis prone group have lower HbA1c than ketosis-onset group. Conclusions. Ketosis-onset diabetes and ketosis prone diabetes do not absolutely have the same clinical characteristics. Each subgroup shows different specialty.
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Affiliation(s)
- Beiyan Liu
- Endocrinology and Metabolism Department of the Second Hospital Affiliated to Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province 150086, China
| | - Changhua Yu
- Endocrinology and Metabolism Department of the Second Hospital Affiliated to Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province 150086, China
| | - Qiang Li
- Endocrinology and Metabolism Department of the Second Hospital Affiliated to Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province 150086, China
- *Qiang Li:
| | - Lin Li
- Endocrinology and Metabolism Department of the Second Hospital Affiliated to Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province 150086, China
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Tan H, Zhou Y, Yu Y. Characteristics of diabetic ketoacidosis in Chinese adults and adolescents -- a teaching hospital-based analysis. Diabetes Res Clin Pract 2012; 97:306-12. [PMID: 22704172 DOI: 10.1016/j.diabres.2012.05.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 08/29/2011] [Accepted: 04/24/2012] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the diabetic ketoacidosis (DKA) episodes occurred in diabetic adults and adolescents. METHODS We reviewed diabetic patients of admissions with DKA in West China Hospital in Chengdu from January 1, 2008 to December 31, 2008. Clinical and laboratory data including β-cell function and autoantibody status were collected respectively. Patients were classified as having type 1 or type 2 diabetes or atypical diabetes based on clinical diagnosis and treatment history. And groups were compared for differences in vital statistics and biochemical profiles at presentation. RESULTS Detailed and accurate information was obtained in relation to 263 of patients accounted for the 287 admissions admitted for DKA, of whom 41 patients had type 1 diabetes (15.59%) meanwhile 178 patients were diagnosis as T2DM (67.68%), and 37 patients could not be "typed" were classified as atypical DM (14.07%). In addition, there were two gestational diabetes mellitus (GDM) and five patients with other specific types. Sixty admissions (22.81%) were newly diagnosed diabetes, of which 28 admissions (46.67%) were atypical diabetes. The most common contributing factor for DKA was infection (39.16%), followed by noncompliance with anti-diabetes treatment including omission of insulin (25.5%), unknown causes (25.86%) and other medical conditions (11.73%). Of note, these middle-age obese male patients with atypical diabetes often lapse into diabetic ketoacidosis without identifiable precipitating factors. CONCLUSIONS DKA could occur not only in T1DM but also in patients with T2DM under infection or stress condition, furthermore without any identifiable precipitant. The prevalence of DKA and its clinical heterogeneity have significant implications for diagnosing and classification of diabetes. More attention and prevention strategies are needed in ketosis-prone atypical diabetes.
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Affiliation(s)
- Huiwen Tan
- Division of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, 610041, PR China
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Abstract
Diabetes affects today an estimated 366 million people world-wide, including 20 million to 40 million of patients with type 1 diabetes (T1D). While T1D accounts for 5% to 20% of those with diabetes, it is associated with higher morbidity, mortality and health care cost than the more prevalent type 2 diabetes. Patients with T1D require exogenous insulin for survival and should be identified as soon as possible after diagnosis to avoid high morbidity due to a delay in insulin treatment. It is also important to present to the patient correct prognosis that differs by the type of diabetes. From the research point of view, correct classification should help to identify the etiologies and to develop specific prevention for T1D. This review summarizes evidence that may be helpful in diagnosing T1D in various ethnic groups. Challenges in interpretation of results commonly used to determine the type of diabetes are highlighted.
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Affiliation(s)
- Marian Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
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Smiley D, Chandra P, Umpierrez GE. Update on diagnosis, pathogenesis and management of ketosis-prone Type 2 diabetes mellitus. ACTA ACUST UNITED AC 2011; 1:589-600. [PMID: 22611441 DOI: 10.2217/dmt.11.57] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Diabetic ketoacidosis (DKA) has been considered a key clinical feature of Type 1 diabetes mellitus; however, increasing evidence indicates that DKA is also a common feature of Type 2 diabetes (T2DM). Many cases of DKA develop under stressful conditions such as trauma or infection but an increasing number of cases without precipitating cause have been reported in children and adults with T2DM. Such patients present with severe hyperglycemia and ketosis as in Type 1 diabetes mellitus but can discontinue insulin after a few months and maintain acceptable glycemic control on diet or oral agents. This subtype of diabetes has been referred to as ketosis-prone T2DM. In this article, we reviewed the literature on ketosis-prone T2DM and summarized the epidemiology, putative pathophysiology and approaches to management.
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Affiliation(s)
- Dawn Smiley
- Emory University School of Medicine, Division of Endocrinology & Metabolism, Atlanta, GA 30303, USA
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Roy MS, Janal MN, Roy A. Medical and psychological risk factors for incident hypertension in type 1 diabetic african-americans. Int J Hypertens 2011; 2011:856067. [PMID: 21876788 PMCID: PMC3163036 DOI: 10.4061/2011/856067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 05/13/2011] [Accepted: 05/26/2011] [Indexed: 11/28/2022] Open
Abstract
Objective. To determine risk factors for the development of hypertension among African-Americans living with type 1 diabetes.
Methods. African-Americans with type 1 diabetes (n = 483)
participated in a 6-year followup. At both baseline and followup blood pressure was measured twice in both sitting and standing positions using a standard protocol. Patients had a structured clinical interview, ocular examination, retinal photographs, and blood and urine assays and completed the Hostility and Direction of Hostility Questionnaire (HDHQ) and the Beck Depression Inventory (BDI).
Results. Of the 280 diabetic patients with no hypertension at baseline, 82 (29.3%) subsequently developed hypertension over the 6-year followup. Baseline older age, longer duration of diabetes, family history of hypertension, greater mean arterial blood pressure, overt proteinuria, increasing retinopathy severity, peripheral neuropathy, smoking, and higher hostility scores were significantly associated with the development of hypertension. Multivariate analyses showed that higher hostility scores and overt proteinuria were significantly and independently associated with the development of hypertension in this population.
Conclusions. The development of hypertension in African-Americans living with type 1 diabetes appears to be multifactorial and includes both medical (overt proteinuria) as well as psychological (high hostility) risk factors.
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Affiliation(s)
- Monique S Roy
- Department of Ophthalmology, University of Medicine and Dentistry, New Jersey Medical School, Institute of Ophthalmology and Visual Science, 90 Bergen Street, Room 6164, Newark, NJ 07101-1709, USA
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Irving RR, Wright-Pascoe R, Mills JL, Choo-Kang EG, Mclaughlin WA, Mullings AA, McGrowder D. Mosaic pancreas or type 3 diabetes: how do we define it? Int J Diabetes Dev Ctries 2011. [DOI: 10.1007/s13410-011-0028-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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HLA class II alleles susceptibility markers of type 1 diabetes fail to specify phenotypes of ketosis-prone diabetes in adult Tunisian patients. EXPERIMENTAL DIABETES RESEARCH 2011; 2011:964160. [PMID: 21461382 PMCID: PMC3063415 DOI: 10.1155/2011/964160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 12/28/2010] [Accepted: 01/10/2011] [Indexed: 11/18/2022]
Abstract
We aimed to characterize the different subgroups of ketosis-prone diabetes (KPD) in a sample of Tunisian patients using the Aβ scheme based on the presence or absence of β-cell autoantibodies (A+ or A-) and β-cell functional reserve (β+ or β-) and we investigated whether HLA class II alleles could contribute to distinct KPD phenotypes. We enrolled 43 adult patients with a first episode of ketosis. For all patients we evaluated clinical parameters, β-cell autoimmunity, β-cell function and HLA class II alleles. Frequency distribution of the 4 subgroups was 23.3% A+β-, 23.3% A-β-, 11.6% A+β+ and 41.9% A-β+. Patients from the group A+β- were significantly younger than those from the group A-β- (P = .002). HLA susceptibility markers were significantly more frequent in patients with autoantibodies (P = .003). These patients also had resistance alleles but they were more frequent in A+β+ than A+β- patients (P = .04). Insulin requirement was not associated to the presence or the absence of HLA susceptibility markers. HLA class II alleles associated with susceptibility to autoimmune diabetes have not allowed us to further define Tunisian KPD groups. However, high prevalence of HLA resistance alleles in our patients may reflect a particular genetic background of Tunisian KPD population.
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